ConservativeHome's 100policies

Jonathan Munday: "Medicalise" illegal drugs

> Policy summary

To "medicalise" the provision of currently illegal drugs, by providing them through NHS clinics to British Citizens. The sale is subject to an excise duty to help fund the NHS.

> Policy explanation

Prohibition of illegal drugs has failed just as much as prohibition of alcohol failed in the USA and with the same terrible consequences to public morality and law and order. But legalisation of drugs is politically inexpedient and would legitimise the businesses of some of the nastiest criminals in the UK.
Drugs should be available at cost plus an excise duty to registered users at special NHS clinics. The price in the NHS clinics should be adjusted quarterly so that it is half the then current street price. If need be, initially, the NHS would give the drugs away free until the monopoly was secured and the illegal drug industry driven out of business by the law of the market.

The NHS would become a monopoly supplier of illegal drugs and use the power of the market to undercut and drive out the dealers. Drugs would remain illegal and anyone caught dealing (or in unregistered possession) would be subject to the full might of the law and employers would be able to sack employees stoned on business. The clinics would dispense clean needles, syringes etc and provide uncut pure product. They would supply any drug requested in any quantity, provided it could be proved to be for personal use (by consumption of a test dose on the premises).

Ultimately, it must be accepted that prohibition has failed and will continue to fail. If children are going to take drugs, would you rather they got them from a gun-toting psychopath on a street corner or from a doctor in a clinic? Telling teenagers that drugs aren't daring or clever but mean that they are sick and need to go to the doctor for them is a very powerful message for that age group. Once the government had achieved a monopoly, it could start to raise prices to cut consumption, as with cigarettes.

This is not just a policy for drug addicts. They are buying and using the drugs now and it is better that this share of the GDP swells our government's treasury, rather than those of Afghanistan and Columbia. It is a policy for the rest of society. Most petty crime is drug related as addicts steal or prostitute themselves to maintain their artificially expensive habit. Cheap pure drugs would leave them too stoned to steal. Most of the medical consequences of drugs are a function of their illegality. Cut impure drugs risk overdosing and dirty needles spread HIV. This would be much less an issue.

What medicalisation actually does is to nationalise the illegal drugs industry. Nationalising an industry to ensure it decays and collapses is a very Tory policy - privatisation in reverse.

> Political risks and opportunities

The chief problem with the policy is the amount of political will it would need to see it through. Admitting that 50 years of drug policy was wrong is hard enough. Telling the Chief Commissioners that you no longer need half their police forces or most of the prisons and numerous social and charity workers that they can stop bothering now is an attack on some of the most vested interests in modern Britain.

Then there is the problem of the public brainwashed by 50 years of ceaseless official propaganda into just saying no - although the size of the current illegal industry does suggest that this might not be as big a problem as those some officials may expect. Finally, there is the attitude of several senior Colombian and Russian businessmen, who may "vote" against the politician that brought this idea forward.

It is vital that the logic of the system is carried through. In order to gain a market monopoly, the NHS must be prepared to dispense any quantity of any drug for personal use. There will inevitably be a view that dispensing the drugs indicates official recognition or support for drug taking. This is partly offset by their use remaining illegal to unregistered users. Drug counselling would be available in the clinics and might even become compulsory.

Dispensing illegal drugs would risk making Britain a Mecca for every addict in Europe, so clinics would only be open to UK citizens, via an Identity Card.

> Costs

The system has start-up costs, setting up the clinics (the legal production of illegal drugs costs peanuts) but much of this is already spent on hospital DDUs. NHS doctors could be invited to tender for the service in their locality. This also already happens to a limited extent with GP Enhanced services.

The system produces very considerable savings in the medium term:

a) £2-3 billion in excise duty would help fund the rest of the NHS.
b) Since 70%+ of minor crime is reckoned to be drug related and many city murders are score settling between drug gangs, the monopolisation of the market by the NHS will significantly cut crime resulting in huge savings in prison and police costs.
c) Cutting crime will also reduce insurance costs for home and car insurance
d) The current illegal drugs market is perhaps £9-10 billion. All of it is imported. Eliminating it involves a huge improvement in our balance of trade "invisibles".

 

Rachel Joyce: Localise the NHS and integrate health and social care

Rachel Joyce is a doctor and a director in a Primary Care Trust.

> Policy summary

There is significant duplication of resources between health and social care, and at the same time there are major gaps in care, particularly for the elderly population. Localising the NHS would improve accountability and enable integration with social care services, which would not only dramatically improve efficiency, but would also improve outcomes and the care experience for patients.

> Policy Explanation

The recent significant rise in expenditure on the NHS has not resulted in significant improvements in health outcomes as compared to other OECD countries. Moreover, there has been a measurable reduction in NHS productivity. The NHS is a centrally driven monolithic organisation with an artificial divide between it and local government-run social care services.
There is significant duplication of resources by the NHS and social care services, at the same time as major gaps in meeting local needs. For instance, an elderly person living at home may be visited by a district nurse as well as a care worker on the same day. Either one may be able to meet the patient’s whole needs on that day, freeing up the other member of staff to meet other people’s needs, but artificial divisions in regard to what is a “health need” and a what is a “social need” lead to the inefficient use of both.

Furthermore, poor communication between the NHS and social care, as well as perverse incentives can see vulnerable patients “slipping through the net”, often leading to poorer outcomes for patients at higher long term cost to the tax payer. An example is the hospital admission that could have been avoided or shortened if the GP or hospital could have easily accessed social care that met the patient’s needs in a timely fashion. Hospital admission is usually more expensive than care at home, is less popular with patients, and can lead to undesirable consequences such as hospital acquired infection, or confusion in the elderly. The problem is that although better social care for this type of patient is an efficient and effective use of resources, it benefits the NHS, but is funded by social services (creating perverse incentives). There are also many other examples of perverse incentives that work the other way (such as better and more rapid stroke care and prevention paid for by the NHS can lead to a significant reduction in the need for social care services for these patients). 

In an attempt to overcome these problems, significant management resource is expended by both NHS and social services managers in “partnership working”, attempting to find ways around these gaps and duplications. However the perverse incentives are difficult to deal with in organisations facing budget deficits and no amount of management resource can deal with the root cause of this problem, and this management resource could be better employed elsewhere in the system.

By localising the NHS, there would be improved local planning that is based on LOCAL need, greatly improved efficiency, better health and social care outcomes, and increased patient satisfaction. Moreover, the services would be more accountable to local people, which will result in better engagement and ownership of people in regard to their own health. Improved efficiency of services could make the Wanless Social Care recommendations (extending social care) an affordable option.

Other advantages to localising the NHS include closer links with education and housing (which are run by local government), leading to further improvements in outcomes and efficiency (housing solutions such as “extra-care housing” can reduce the need for health and social care as well as the need for admission to nursing homes, and education is a major wider determinant of health).

Options for the method of localisation would include either:

• The Local NHS run or commissioned by local government (as social care is currently) with some central running of highly specialised services. An advantage is that it would also facilitate good links with education and housing. Accountability would be to the local electorate.
• A choice of More than one health and social care maintenance organisation available at a local level, funded by local or central government on the basis of their patient demography. This would provide the patient with a choice of health and social care organisation, and introduce an element of competition. Accountability would be direct to the patient, who can move their funding to another organisation if not satisfied.

> Political Risks and Opportunities

Risk: The NHS is thought of as a national treasure, and changing the way it works may lead to some concerns. However, improved efficiency and outcomes as well as accountability should reap early benefits.

Opportunity 1: The Government has so far failed to act on the recommendations by the Wanless Social Care Review. Localising the NHS and integration with social care could make these recommendations an affordable option.

Opportunity 2: The different local options (local government run/ commissioned or choice of organisation) will improve accountability, and the latter would lead to better choice.

> Questions for ConservativeHome Readers

• Should the policy include adopting the Wanless Social Care recommendations?
• Should the system be run/ commissioned by local government, or should patients have a choice of organisation?

> Policy Costs

There would be some minimal administrative costs in the short term, but probably no more than is spent on the constant minor reorganisations the NHS is subject to.  In the medium and long term, there would be improved efficiency and therefore improved cost-effectiveness compared to the current arrangements.

Will East: Open the NHS up to new providers, competing on price

Will East graduated from St John’s College, Oxford in 2005, and is training to become a barrister. He runs a political blog, John Wilkes, which focuses on civil liberties issues.

> Policy summary

Open the NHS up to new providers, competing on price

This would involve:

• Allowing private and voluntary sector providers to petition the NHS to let them provide better services
• Giving a statutory duty to primary care trusts, who commission NHS services, to consider each petition
• Changing the payment by results system, so that clinical providers can compete on price as well as quality.

> Policy explanation

Huge amounts of money have been pumped into the NHS over the last years - but there hasn't been an equivalent improvement in the service that patients receive. The health service is the third biggest employer in the world - after the Chinese state army and the Indian railways. But still it's nowhere near the best health service in the world. If we avoid reforming the NHS, then it will face a crisis: an increasingly elderly population and the higher costs of drugs and technology mean that the health service budget will be stretched more than ever before.

At the moment, we're failing to make use of the expertise that's out there among private and voluntary sector organisations, who have experience of providing healthcare efficiently and to a high standard. And, worst of all, there's often little or no stimulus for the hospitals, treatment centres and primary care clinics that make up the NHS to get any better. The government has done something about this, by introducing new providers into the health service - such as the privately run treatment centres that provide routine operations like cataract ops. But, it's nowhere near enough. Given recent form, and with the huge spending splurges of recent years drying out, the NHS will be facing a real financial crisis by the next election - and a Conservative government would need to do something about it.

The government's current reforms are building inefficiency into the system. The system of "payment by results" (by which hospitals are paid) is essentially a fixed price system, which makes hospitals compete on patients, but not on price. This means that there is no incentive for inefficient ways of working to be eradicated, and for costs to be driven down.

I propose that:

• Private and voluntary sector providers should be allowed to petition to run NHS services which are currently inefficient or poor in quality.

These organisations would petition primary care trusts, saying that they could run a service better than the present provider. Well performing NHS organisations, such as foundation trusts, would also be allowed to petition. If successful, they would then be able to take over that service. This principle could be applied to all NHS services, from back office work, such as payroll, to operations and general practice.

• Giving a statutory duty to primary care trusts, who commission NHS services, to consider each petition

There would need to be a statutory duty for primary care trusts, as commissioners of 75% of NHS services, to consider each petition they receive, examine the provider's proposals to see if they would provide better value for money and quality, and consult patients for their views. The PCTs would be required, at the same time, to announce that an offer has been made to take over the service in question, allowing other providers to also petition and try and beat the original offer.

At the end of this, the primary care trust would be required to make an objective assessment of the merits of the offers, and whether they would provide a better service than the existing provider. If so, the provider with the best offer would take over the service. Staff under employment with the incumbent provider would be transferred to the new provider initially if it so wishes. The new provider would have complete managerial power to reorganise the way the service is provided.

After a service has been taken over by a new provider, there would then be a moratorium on subsequent petitions for a period of 5 years. This would give more of an incentive for organisations to petition in the first place (as they would be guaranteed an income stream for 5 years if they won) and prevent constant petitioning from occurring.

• Changing payment by results, so that clinical providers can compete on price as well as quality.

At the moment, organisations which supply clinical services to the NHS (be they from the private, voluntary or public sector) are paid a fixed price known as the NHS tariff. The price paid for each type of operation is decided under the system and paid whenever the hospital provides that operation to a patient. This builds inefficiency into the system (see above). It would also prevent the idea of new providers petitioning to run services more efficiently, as these providers would only be able to compete on the basis of better quality services, not price.

I therefore propose that the fixed price system be abolished, in favour of a "benchmark" price that represents the average price of a particular operation across the NHS. New providers could offer to take over services, at prices that are lower than the benchmark price. Gradually, as these providers took over services, the "benchmark" price would come down, forcing incumbent providers like NHS hospital trusts to become more efficient. This would not be to the detriment of quality services for patients - as commissioners, when receiving petitions, would have to consider the effect of a new provider taking over on quality of service, as well as price.

> Political risks and opportunities

Opportunities:

• This would be a really radical solution to reforming the NHS, increasing efficiency for taxpayers and quality for patients
• It would be a solution which Labour would not be willing to adopt - making it a distinctive Conservative policy
• It would help pave the way for future tax cuts and the reduction of the £90bn plus health service budget

Risks:

• It would face a hail of protest from Labour and the unions, with accusations of "privatisation" and of the Conservative party returning to its "extremist" roots
• It would be a difficult policy to explain to voters, as Labour's policies on choice have been

> Questions for Conservativehome readers:

• Should patients be allowed to petition for new services to be provided, too?
• If so, what should be the mechanism for this?
• Should the moratorium period for subsequent petitions be longer than 5 years?
• What about services which are provided or commissioned on a national basis (eg the NHS IT programme)?

> Costs

Start-up costs

There would need to be extra employees within primary care trusts to consider the petitions in detail. As a policy affecting the whole of the healthcare system, the project would also require considerable resources to be devoted to it within the Department of Health and local NHS organisations. Having said that, there are already expert teams operating the payment by results system at national and local levels.

Running costs

The system would actually reduce the cost of the health service budget significantly, whilst improving quality for patients.

 

Karen Bradley: Single measles, mumps and rubella (MMR) vaccines to be available through the NHS

Karen Bradley was recently selected for Staffordshire Moorlands.

> Policy summary

Single measles, mumps and rubella (MMR) vaccines to be available through the NHS.  Labour’s policy of forcing the combined MMR vaccine onto parents and doctors puts children at unnecessary risk.

> Explanation of policy

This is not a medical argument, but an argument of principle and responsibility.

To protect their children from measles, parents have three choices;

• a combined MMR vaccine free through the NHS,
• three single vaccines paid for privately or
• not have their children vaccinated. 

Parents’ lack of confidence in MMR means that many are leaving their children unvaccinated – take-up rates declined from 92% in 1995 to 84% in 2002 – leaving them at risk of contracting measles. 

I must declare an interest – I have decided that I do not want my two young sons to have MMR.  Despite the arguments in favour, I do not want to inject them unnecessarily with Rubella before they are 15 months old.  But I can afford to pay for my sons to be vaccinated privately.  Many parents are not so lucky.

Before MMR was introduced in 1988, there was a single measles vaccine, at about 15 months, and then girls had a rubella vaccine at age 11 – I clearly remember standing in line at school to be given mine.  Mumps vaccine was not generally given.  From 1988 to 1999, parents were given the choice of the combined or single vaccines on the NHS.

Then, Labour took away the choice and made MMR the only option.  They said that many parents had failed to give their children all the single vaccines. 

About that time a report was published suggesting a possible link between MMR and autism and Crohn’s disease.  Together with general concern about giving such young babies so many vaccines in one go, this has led to the reduced take up in childhood vaccination.

Watching this reduction, a pragmatic government – one that was not so anxious about losing face – would re-license single vaccines on the NHS.  Instead, Labour has continued, in its authoritarian way, to insist that only MMR can be given and take-up continues to be low.

> Political risks and opportunities

There is little inherently wrong with MMR.  I do not propose that it should no longer be available.  But Labour’s approach is symptomatic of so many of its policies – we know best, people cannot be trusted to make their own decisions, but it won’t affect us because we can afford to buy our way out of the problem. 

Restoring choice would be popular with parents who feel that they are forced into giving their children a vaccine that they don’t really trust.  It would also show that Conservatives trust parents and doctors to decide what is best for their children and patients.

Questions for ConservativeHome readers

• At what age should the single vaccines be administered?  Pre-school?  Or older?  Rubella vaccine was historically given to girls at age 11/12, should it be given at a younger age?  Measles itself is potentially fatal, so all children should be vaccinated against it at 15 months.
• Should boys be given the rubella vaccine at all?  The argument is that as a country we have decided that we want to eradicate rubella completely and this can only be done with a minimum 95% vaccination programme (WHO guidance).  But as rubella is not dangerous to boys, do they need it so soon, or at all??

> Cost

There is an additional cost in the single vaccines compared to the combined one.  But the cost of Labour’s current policy is that children are running the risk of catching potentially fatal measles merely because Labour does not want to lose face.

Jonathan Sheppard: A frontline role for community pharmacists

Jonathan Sheppard is Editor of ToryRadio.

> Policy summary

The Health Service, and in particular primary care is coming under increased pressure to deliver. An untapped resource - in the shape of the local pharmacist - can and should be used to relieve pressure on an under-delivering NHS.

> Policy explanation

NHS resources are stretched to breaking point. The Government claims that funding is at record levels yet actual health outcomes are failing to show improvements. Money continues to be wasted on bureaucracy and isn't targeted to the areas where it will achieve the best results for healthcare.

People still use NHS services inappropriately. For example, hospital A&E departments are full of people who could be dealt with by their GP in a primary care setting. At the same time, GPs are unable to spend quality time with people who need more specialist care because their surgeries are filled with people who have minor ailments that can be dealt with elsewhere.

People need to take responsibility for their own health to prevent or delay long term illnesses in the future. The under utilised resource is community pharmacy.

Pharmacists are highly skilled professionals - they go through five years of training - they are experts in medicines and have far more knowledge on the subject than any other health professional including GPs. Pharmacists are accessible where people live, shop and work 24/7 and should be the first port of call and entry point to the NHS.  It is estimated that six million people visit pharmacies daily.

With the new pharmacy contract, pharmacists are helping people manage their illnesses and providing support and advice to those with chronic diseases like diabetes, asthma and heart disease. They are already prescribing repeat medicines for patients instead of them visiting the GP every time. Additionally two thirds of patients do not understand their medicines, half of patients stop preventative medication within 1 year, 60% patients forget to take medication regularly and 82% of patients want to know more.

Using pharmacists, patients can be enabled to understand their medicines better - it will save lives, improve health outcomes, empower patients to look after their health better and prevent ill health.

Demands on the NHS are only going to increase over time, It is imperative to use the skills and resources in the NHS as effectively as possible and that means there is the need to get the right professional for the right job.  Pharmacists are an untapped resource in the NHS.

One of their key roles would be to ensure that medicines are being used properly, reducing wastage, increase effectiveness and thereby improve health outcomes.  This would deliver Win for Govt a Win for NHS and most importantly a Win for patients.

> Questions for ConservativeHome readers

• Is there a specific financial cost given to a patient visiting their GP?
• How many GP visits are there per year?
• How many could be equated as unnecessary and dealt with by a pharmacist?

> Costs

There should be no overall cost as any additional spend, could be redistributed resources and money from secondary care to primary care as improvements to health flow through.